Debt deal could hurt programs crucial to internal medicine

Politicians often choose to wait until the absolute last minute to strike a deal on
difficult decisions. Never before, though, has the brinkmanship involved a potential
default of the United States' legal obligations to pay its bills—the debt ceiling.

This year Republicans vowed to use the debt ceiling, which authorizes more borrowing
to meet the United States' already authorized legal commitments, to force an agreement
to reduce future spending. Although President Obama and most Democrats initially resisted
tying the debt ceiling to a deficit reduction plan, they later came along.

Throughout the debt ceiling debate, ACP advocated for several priorities. First, the
College urged that an agreement be reached in time to prevent a potential disruption
of Medicare and Medicaid payments to physicians. Second, ACP advocated that a permanent
solution to the Medicare Sustainable Growth Rate (SGR), which causes annual scheduled
cuts in physician payments, be included in a debt ceiling agreement, noting that the
budget cost of fixing the SGR and preventing further cuts has increased each year
that Congress has failed to enact a solution. Third, ACP agreed that federal health
spending needs to be reduced, but urged continued and adequate funding for critical
programs, including Medicare graduate medical education (GME) and other programs to
train more internal medicine specialists. Finally, the College recommended that reductions
in federal health spending be achieved by working with the profession to target key
cost drivers, such as reducing marginal and ineffective care, basing coverage on clinical
effectiveness with consideration of cost, and providing physicians and patients with
information on comparative effectiveness. Realistically, though, ACP and other interest
groups had very limited ability to influence the final agreement that was negotiated
behind closed doors by congressional leaders from both parties and the president.

Meanwhile, House Republicans, Senate Democrats and the White House strongly disagreed
on how to reduce the deficit. It wasn't until two days before the projected default
date of Aug. 2 that they reached a compromise. The final agreement gives President
Obama the authority to increase the debt ceiling in two stages through 2012, but with
conditions. Congress must enact $900 billion in cuts to discretionary spending programs
(including defense and domestic programs) over the next 10 years. Future spending
is capped to ensure that the required savings are reached. This is where the danger
lies for the future of primary care.

A “super-committee” of Congress, made up of an equal number of House
and Senate Democrats and Republicans, will identify another $1.5 trillion in additional
savings from entitlement programs such as Medicare and Medicaid. The super-committee
will make its report in November, and Congress has until Dec. 23 to cast an up-or-down
vote on its recommendations. If the super-committee can't reach an agreement, or if
Congress votes its recommendations down, another $1.2 trillion in across-the-board
cuts, split equally between domestic programs and national defense, would be triggered,
including cuts in Medicare payments to clinicians (but with no cuts in benefits);
Medicaid and Social Security are exempted. The trigger mechanism is intended to put
pressure on the super-committee to come up with the necessary savings and for Congress
to agree to them, the thinking being that Republicans would not want to see defense
spending cut and Democrats would not want to see Medicare and other domestic programs
cut.

How does the agreement measure up? It prevents a default situation where the federal
government might have had to suspend Medicare and Medicaid payments to physicians.
It does not mandate any immediate GME cuts, but it also doesn't include a solution
to the SGR.

The real impact of the agreement on internists and their patients, however, won't
be known until Congress decides how to reach the required savings. Mandated cuts in
discretionary programs could result in underfunding or even eliminating programs aimed
at addressing a growing shortage of internal medicine specialists and other primary
care physicians, such as Title VII primary care training grants, National Health Service
Corps scholarships and loans, and grants to help physicians become patient-centered
medical homes. Medical and health services research and the ability of the Centers
for Disease Control and Prevention and the Food and Drug Administration to protect
the public from preventable diseases and unsafe drugs and foods could be compromised.

Congress' super-committee could recommend major changes in Medicare, including structural
changes like increasing the eligibility age and requiring that higher-income beneficiaries
pay more. It could also impose cuts on GME funding for internal medicine training
programs, cut pay for high-cost procedures, or even try to force physicians into untested
new payment models. And Medicare payments to physicians could be subject to across-the-board
cuts if the trigger mechanism is invoked, as if the SGR wasn't enough for physicians
to worry about.

As Congress goes about its work of finding the required savings, ACP will continue
to urge it to focus on the true cost drivers behind increased health spending, such
as the hundreds of billions spent on overutilization of marginal and ineffective care,
instead of slashing reimbursement to internists or cutting spending on critical programs
to improve care access and quality and address physician workforce shortages.

Internal medicine physicians are specialists who apply scientific knowledge and clinical expertise to the diagnosis, treatment, and compassionate care of adults across the spectrum from health to complex illness. ACP Internist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated.